New Warme Patient Form Name Date Age Please Check one: Right Handed Left Handed Ambidextrous How did you hear about us? Requesting Physician Name UPIN # Address City State Zip Code Phone Fax email Primary Care Physician Name UPIN # Address City State Zip Code Phone Fax email Is this a work related problem? Yes No If yes, list your OWCP Claim# If disabled, when did you last work? or L&I Claim# Is a lawyer involved with this problem? If so, name/address Affix Pt Label Here Name: U Number: DOB: DOS: Chief Complaint - Please describe the problem that brings you into the office today: History of Present Illness 1. Where is the problem located? Right Left Both / Shoulder Elbow Knee Ankle Please specify: 2. When and How did this problem begin?(date of injury) 3. Circle the symptoms that best describe your problem: Stiffness Pain Instability Weakness Roughness Other 4. If you have pain, please circle the description(s) that are most appropriate: Sharp Throbbing Aching Burning Stabbing Heavy Dull 5. Please rate the intensity of your joint Pain/discomfort: (1 = No Pain, 10 = Severe Pain) 1 2 3 4 5 6 7 8 9 10 6. Is your pain getting: Better gradually Better rapidly Worse Worse gradually Worse rapidly 7. What improves your symptom(s)? NSAIDs Injections Physical Therapy 8. What makes your symptom(s) worse? 1
Past Medical History 1. Do you have, or are you being treated for, any of the following (please check all that apply): Allergies (allergic rhinitis) Anxiety Asthma Bipolar Bleeding/clotting disorder Cancer (CA) Chemical/Alcohol dependency Chronic lung disease/emphysema (COPD) Congestive heart failure (CHF) Coronary artery disease (CAD) Depression Diabetes (using insulin)(iddm) Diabetes (no insulin)(niddm) Fibromyalgia Heartburn/reflux (GERD) Medications: Heart attack (MI) Hepatitis (please specify type(s)) High blood pressure (HTN) High cholesterol Psoriasis Rheumatoid Arthritis (RA) Stomach ulcers/peptic ulcer disease (PUD) Stroke/transient ischemic attack (TIA) Thyroid disorder (please list) Sleep Apnea Other Sleep disorder/trouble sleeping/(insomnia) Other (specify) 1. Are you taking any pain medications YES NO If so, please list all: Pain Medications Dose Times per day Reason for taking 2. All other Medications Dose Times per day Reason for taking 2
Past Surgical History 1. What studies have you had for this problem? (Check all that apply) X-rays CT MRI Nerve Study (EMG) Arthrogram Bone Scan Other: 2. Have you had any previous surgeries for this problem? Yes No Surgeries for This Problem and if they helped Surgeon Year 3. List all Other Bone/Joint (Orthopedic) Surgeries. Surgeries Year 4. Please list/check all Other Surgeries you have had. Surgeries Year No previous surgeries Appendix (appendectomy) Gall bladder (cholecystectomy) Bypass/open heart (CABG) Hernia Repair Hysterectomy Tonsils removed (tonsillectomy) Other Surgeries Year Affix Pt Label Here Name: U Number: DOB: DOS: 3
Allergies 1. Do you have any allergies? Yes No if so, please list To Medications? To Foods? 2. Are you allergic to latex? Yes No 3. Are you allergic to iodine? Yes No Review of Symptoms Do you have or had any of the following Problems? (Check any that apply) General Eye Ear/Nose/Throat Heart Lung Stomach Muscles/ Bones Urinary Tract Skin Neurology Mental Health Endocrine Blood/Lymph Immunological weight gain weight gain loss fatigue glasses/contacts cataracts sinus trouble hearing loss irregular heartbeat high blood pressure chest pain shortness of breath difficulty breathing decreased appetite constipation heartburn arthritis fractures kidney stone bladder/kidney infections masses blisters seizures tingling anxiety depression increased thirst diabetes insomnia fever night-sweats/chills glaucoma ringing in ears fluttering in chest coronary disease lung disease persistent cough nausea diarrhea hepatitis A B C sprains prostate problems painful urinating non-healing wounds dermatitis numbness severe headaches other (please describe) thyroid bleeding or clotting problems anemia swollen or enlarged lymph nodes hay fever HIV/AIDS lupus Comments 4
Family History Please check if any of your family members have had the following: Anesthesia/anesthetics problems Arthritis Cancer Clotting Disorder Other Depression Diabetes Gout Heart Attack High Blood Pressure Kidney disorder Rheumatoid Stroke Social History 1. Are you currently working? Yes No What is or was your occupation? 2. Are you married? Yes No Other Relationship: 3. Do you have any children? Yes No # 4. How many individuals live with you now? 5. Do you smoke or use tobacco? Yes No How many packs or cans per week? 6. Do you consume alcohol? Yes No How many drinks per week? 7. Do you currently or have you ever had a problem with drug or alcohol abuse? Yes No (If yes, explain below) SANE Score How would you rate your affected and opposite extremity today as a percentage of normal (0% to 100% scale with 100% being normal)? Right Side: % Left Side: % Other Information Is there anything else we should be aware of or you would like to tell us? Affix Pt Label Here Name: U Number: DOB: DOS: Physician Signature Date 5
If you have a shoulder problem, please fill out the Simple Shoulder Test on page 7 for BOTH of your shoulders. If you have a elbow problem, please fill out the Elbow Shoulder Test on page 8 for BOTH of your elbows. 6
Simple Shoulder Test Dominant Hand (fill in only one circles): Right Left Ambidextrous Please answer YES or NO for both of your shoulders 1 2 3 4 5 6 7 8 9 10 Is your shoulder comfortable with your arm at rest by your side? Does your shoulder allow you to sleep comfortably? Can you reach the small of your back to tuck in your shirt with your hand? Can you place your hand behind your head with the elbow straight out to the RIGHT LEFT YES NO YES NO 1 2 3 side? 4 Can you place a coin on a shelf at the level of your shoulder without bending your elbow? 5 Can you lift one pound (a full pint container) to the level of your shoulder without bending your elbow? 6 Can you lift eight pounds (a full gallon container) to the level of your shoulder without bending your elbow? 7 Can you carry twenty pounds at your side with this extremity? Do you think you can toss a softball under-hand twenty yards with this 8 extremity? 9 Do you think you can toss a softball over-hand twenty yards with this extremity? 10 11 Can you wash the back of your opposite shoulder with this extremity? 11 12 Would your shoulder allow you to work full-time at your regular job? 12 Office Use Only For Physician to Fill Out DJD SDJD RA FS PTSS AVN CA CTA SA PTCL RCT TUBS AMBRII R Other: DJD SDJD RA FS PTSS AVN CA CTA SA PTCL RCT TUBS AMBRII L Other: Affix Pt Label Here Name: U Number: DOB: DOS: 7
Simple Elbow Test Dominant Hand (fill in only one circles): Right Left Ambidextrous Please answer YES or NO for both of your elbows 1 2 3 4 5 6 7 8 9 10 11 12 Is your elbow comfortable with your arm at rest by your side? Does your elbow allow you to sleep comfortably? Does your elbow allow you to reach the small of your back to tuck your RIGHT LEFT YES NO YES NO 1 2 shirt in? 3 Can you place your hand behind your head with the elbow straight out to the side? 4 Will your elbow allow you to pull on socks or stockings? Does your elbow allow you to lift one pound to the level of your shoulder? Can you use your arm to help you rise from a chair? Will your elbow allow you to carry 20 pounds at your side? Will your elbow allow you to comb your hair? Will your elbow allow you to throw a ball with this arm? Will your elbow allow you to wash the back of your opposite shoulder? Would your elbow allow you to work full-time at your regular job? 5 6 7 8 9 10 11 12 Office Use Only For Physician to Fill Out Cont INST FInR TeEl DiBi LoBo TraA RheA FArh UlnN R Other: Cont INST FInR TeEl DiBi LoBo TraA RheA FArh UlnN L Other: 8